No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Champlain Valley Physicians Hosp Med Ctr S N F

75 Beekman Street, Plattsburgh, NY 12901 · Non profit - Other · 95 certified beds · (518) 562-7760 Medicare & Medicaid certified

Call the home — (518) 562-7760 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 2025
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
206 Cornelia St #306 · (518) 566-9452 · Call to confirm hours
Pharmacy
Grocery
316 Cornelia St · (518) 310-3702 · Call to confirm hours
Park
20 Stetson Ave · (518) 563-1766 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.2%14.1%15.4%typical
Long-stay residents who lose too much weight5.7%5.8%5.4%typical
Long-stay residents with a catheter left in their bladder5.6%0.5%0.9%worse
Long-stay residents with a urinary tract infection7.5%1.3%2.0%worse
Long-stay residents with depressive symptoms6.0%19.5%6.5%typical
Long-stay residents who were physically restrained2.8%0.2%0.1%worse
Long-stay residents with falls causing major injury7.4%3.1%3.3%worse
Long-stay residents whose ability to walk worsened9.2%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.4%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.3%95.3%typical
Long-stay residents with pressure ulcers6.6%6.5%4.7%worse
Long-stay residents with worsening bladder/bowel control19.0%19.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table40.7%13.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents rehospitalized after admission27.6%20.6%22.6%worse
Short-stay residents with an outpatient ER visit19.9%9.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.031.701.67worse
Long-stay outpatient ER visits per 1,000 resident days1.801.361.80typical

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

60.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 135 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.6%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
0.10U.S. median 0.31
Therapy hours / resident / day
<0.01hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF60.6%CMS range 51.0–69.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.7–13.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.8%CMS range 2.7–11.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.581.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

2
deficiencies at the latest standard inspection (2025-01-17)
7
at the previous standard inspection (2022-10-14)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.

  • Potential for harm · D2025-01-17 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review conducted during the recertification survey, the facility did not provide proper treatment and assistive devices to maintain the vision ability for 1 (Resident #28) of 2 residents reviewed for communication. Specifically, Resident #28, who had impaired vision was not assisted in obtaining optometry consultation to be evaluated for vision aids. This is evidenced by: Resident #28 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a long-term breathing problem), hypertension (high blood pressure), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The Minimum Data Set (an assessment tool) dated 11/10/2024, documented the resident was understood, able to understand others, and was cognitively intact. The Minimum Data Set documented the resident had impaired vision and used corrective lenses. Review of the medical record showed no optometry consults were documented for the resident, nor was a comprehensive…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-17 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, cleaning chemicals were not stored properly, equipment was not in good repair or installed safely, equipment and floors were not clean, and the proper testing equipment was not available for checking the concentration of sanitizing solution. This is evidenced by: During observations on 01/13/2025 at 12:29 PM, the following was noted: • Glass cleaner was stored above food processor. • The warewashing area spay hose nozzle was hanging below the sink flood rim in water. • The facility did not have correct test papers to check the sanitizing solution; the test papers presented did not show a 150 parts per million of quaternary ammonium compound graduation and a graduation above 400 parts per million of quaternary ammonium compound; and the sanitizer concentrate label stated the efficacy range was between 150 and 400 parts per million of quaternary ammonium…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-17 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the recertification and abbreviated survey (Case #s NY00346121, NY00366317, and NY00365618), the facility did not ensure the resident's right to be free from abuse and neglect for 3 (Resident #s 1, 14, and 23) of 4 residents reviewed for abuse and neglect. Specifically, (a.) for Resident #1, a staff member grabbed their forearm and removed their call light on 6/23/2024; (b.) for Resident #14, a bed bolster was not in place when one staff member assisted in the resident's care when the resident required two staff, resulting in a fall on 12/22/2024; (c.) for Resident #23, a staff member grabbed their hand resulting in a skin tear. This is evidenced by: A policy and procedure titled, Abuse Prevention, Investigation, and Reporting, revised 8/19/2024, documented the facility would actively protect the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Resident #1 Resident #1 was admitted to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during a recertification and abbreviated survey (Case #NY00366317), the facility did not ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the Administrator of the facility and to the State Survey Agency for 1 (Resident #23) of 4 residents reviewed. Specifically, an allegation of physical abuse observed by staff on 12/25/2024 at 2:00 AM was not reported to the New York State Department of Health within 2 hours after the allegation was made. The allegation was reported to the New York State Department of Health on 12/26/2024 at 3:19 PM. This is evidenced by: The Policy and Procedure titled, Abuse Prevention, Investigation, and Reporting, revised 8/19/2024, stated incidents that resulted in bodily injury must be reported within 2 hours. Resident #23 was admitted to the facility with the diagnoses of dementia, atrial fibrillation (irregular heart rate), and anxiety disorder. The Minimum Data Set (an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during the recertification and abbreviated survey (Case #NY00366317), the facility did not ensure the resident's right to be free from further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress for 1 (Resident #23) of 4 residents reviewed for abuse and neglect. Specifically, Certified Nurse Aide #3 was not removed immediately from resident's care when there was an allegation of physical abuse to prevent further abuse from occurring. Certified Nurse Aide #3 was allowed to work until the end of their shift. This is evidenced by: The facility policy and procedure titled, Abuse Prevention, Investigation, and Reporting, revised 8/19/2024, documented the facility would actively protect the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. When an incident of alleged abuse occurs, the Administrator or designee would be responsible for assuring the resident's security, protection, and confidentiality would be maintained during the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during a recertification and abbreviated survey (Case #NY00365618), the facility did not ensure adequate supervision and assistive devices were provided to prevent accidents for 1 (Resident #14) of 3 residents reviewed for accident hazards. Specifically, Resident #14, who required 2 caregivers for care was assisted with 1 caregiver and a bed bolster was not in place resulting in the resident rolling out of bed. Resident #14 was admitted to the facility with the diagnoses of dementia, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsion, associated with abnormal electrical activity in the brain), and major depressive disorder. The Minimum Data Set, dated [DATE] documented the resident was rarely/never understood, rarely/never understood others, and was severely cognitively impaired. The comprehensive care plan titled, Fall Risk, reviewed 1/10/2025, documented the following intervention: staff would…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-10 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (Case #s NY00343699 and NY00318831), the facility did not ensure that all alleged violations involving abuse was reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the State Survey Agency in accordance with State law through established procedures for 2 (Resident #s 1 and 3) of 4 residents reviewed for abuse reporting. Specifically, allegations of physical and sexual abuse that involved 2 residents was not reported by staff to facility administration within 2 hours. This is evidenced by: The Policy and Procedure titled Abuse Prevention, Investigation, and Reporting revised 8/07/2019, documented if an individual had knowledge that physical abuse had occurred, or had reason to believe so, they must notify the charge nurse, patient care coordinator, Director of Nursing, or Administrator. The Administrator or their designee, having reasonable cause would be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews during the recertification survey dated 10/11/2022 through 10/14/2022, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety in the main kitchen. Specifically, a toxic vapor-emitting fly strip was found in the dishwashing machine area; brooms and dust bins were stored in the cafeteria preparation area; and the floor mixer, bake shop table mixer, microwave oven, can opener holders, bake shop sugar bin, refrigerator door gaskets, cooking line floor under equipment, floor at entrance to the walk-in freezer, and fire extinguishers were soiled with food particles, food splatters, or a grease build-up. This is evidenced as follows: During main kitchen observations on 07/13/22 at 10:45 AM, a toxic vapor-emitting fly strip was found in the dishwashing machine area; brooms and dust bins stored in the cafeteria preparation area; and the floor mixer, bake shop table mixer, microwave oven, can opener holders, bake shop sugar bin, refrigerator door gaskets, cooking line…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-14 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews during the recertification survey on 10/11/2022 through 10/14/2022 the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements related to F656; Development and Implementation of Comprehensive Care Plans, and F697; Pain Management. Specifically, the facility did not ensure that the approved Plan of Correction (POC) for F 656, and F 697 cited during the Recertification Survey completed on 12/19/2019 were implemented, resulting in the same deficiencies being issued during the current survey. This is evidenced by: The facility document titled CVPH Skilled Nursing Facility QAPI Plan, dated September 2019 documented, the purpose of QAPI in our organization is to take a proactive approach to improve the quality of life and quality of care of all residents. Review of the approved Plan of Correction for the Recertification Survey…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-14 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interviews during the recertification survey dated 10/11/22 through 10/14/2022, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for one (1) of 3 medical records reviewed. Specifically, Resident #84 received Medicare Part A services and did not provide notification (2-day notification) of the termination of services with the required form Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC. This is evidenced as follows: During interviews on 10/14/22 at 9:03 AM, the Administrator and Director of Nursing were requested to provide the required Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC (NOMNC) for Resident #84 and stated that though a discharge meeting with Resident #84 was held on 05/20/2022, and the resident agreed that rehabilitative services would end on 05/22/2022, the resident was not provided with a NOMNC. 10 NYCRR 415.3 (g)

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 7 citations
  • Potential for harm · Dcited before2022-10-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey, the facility did not ensure development of comprehensive person-centered care plans, that included measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for three (Residents #,s 6, 7, and #10) of sixteen residents reviewed for comprehensive care plans (CCP). Specifically, for Resident #6, the facility did not ensure a CCP was developed to address the use of oxygen and the use of anticoagulants (blood thinners), for Resident #7, a CCP was not developed to address frequent migraines and for Resident #10, a CCP was not developed to address recent antipsychotic medication. This is evidenced by: Resident #6: Resident #6 was admitted with diagnoses of dementia, atrial fibrillation, and chronic pulmonary embolism. The Minimum Data Set (MDS - an assessment tool) dated 7/3/2022 documented the resident had no cognitive impairment,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews during a recertification survey dated 10/11/2022 through 10/14/2022, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for 1 (Resident #6) of 1 resident reviewed for respiratory care. Specifically, for Resident #6, the facility did not ensure the resident's medical record included documentation of on-going administration of oxygen and monitoring of the resident's respiratory status. This is evidenced by: The Policy and Procedure (P&P) titled Oxygen Therapy Protocol for Adults last revised 3/28/22, did not address documentation or on-going monitoring of residents receiving oxygen therapy. Resident #6: Resident #6 was admitted with diagnoses of dementia, atrial fibrillation, and chronic pulmonary embolism. The Minimum Data Set (MDS - an assessment tool) dated 7/3/2022 documented the resident had no cognitive impairment, could be understood, and usually understand others. Medication Orders dated 9/18/2022, documented maintain to oxygen saturation above 90%…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-14 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during a recertification survey the facility did not ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #'s 7 and #287) of 3 residents reviewed for pain management. Specifically, for Residents #'s 7 and #287, the facility did not ensure the resident's pain levels were assessed, did not ensure that non-pharmacological interventions for pain relief were provided and did not ensure that the effectiveness of as needed (PRN) pain medications were monitored. This was evidenced by: The Policy and Procedure (P&P) titled Pain Management, Skilled Nursing Facility dated 1/30/2020 documented pain, intensity and comfort will be assessed at least every shift after non-invasive interventions, and/or routine/PRN medications have been initiated using the designated pain scales. Resident #7 Resident #7 was admitted with diagnoses of quadriplegia, migraine intractable, and paranoid…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-12-19 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility did not ensure person-centered comprehensive care plans were developed and implemented that included measurable objectives and timeframes to meet the residents needs for 5 (Resident #'s 6, 17, 23, 33, and #286) of 12 residents reviewed. Specifically, for Resident #23, the facility did not ensure that a comprehensive care plan (CCP) was developed for the use of a wound vac and did not ensure the CCP for Multiple Sclerosis (MS) included person centered interventions, for Resident #33 the facility did not ensure that a care plan was developed to include the visitor warning sign on the door to the resident's room, for Resident #286, the facility did not ensure the resident's CCP titled High Risk for Falls included the use of alarms, for Resident #6, the facility did not ensure the resident's care plan for pain included the use of the physician ordered narcotic pain medication and that the care plan included interventions to address the effectiveness of and the resident's response to the pain medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-12-19 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during a recertification survey the facility did not ensure adequate pain management was provided to a resident who required such services, consistent with professional standards of practice for one (1) (Resident #6) of one (1) residents reviewed. Specifically, the facility did not ensure that circumstances for when pain could be anticipated were identified and communicated, did not ensure the resident's existing pain was routinely evaluated for the management and prevention of pain, and did not ensure the use and administration of an as needed (PRN) medication was adequately monitored for effectiveness with the use of a pain scale per standard of practice. Additionally, the facility did not ensure the resident's care plan for pain included the use of the physician ordered narcotic pain medication and interventions to address the effectiveness of and the resident's response to pain medication. This is evidenced by: A Pain Rating Scale shall be completed and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-12-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #23) of one resident observed for dressing changes. Specifically, for Resident #23, the facility did not ensure infection control measures were maintained during a wound vac dressing change. This is evidenced by: Resident #23: The resident was admitted to the facility with the diagnosis of Multiple Sclerosis (MS), quadriplegia and pressure ulcer of the sacral region. The Minimum Data Set (MDS - an assessment tool) dated 11/4/19, documented the resident was cognitively intact, was able to make himself understood and was usually able to understand others. The physician orders dated 11/6/19 documented; Monitor wound vac (vacuum-assisted closure of a wound is a type of therapy to help wounds heal) every shift, pressure ulcer…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-10-14 · tag F0813 — widespread
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview during the recertification survey dated 10/11/2022 through 10/14/2022, the facility did not ensure the policy regarding foods brought to residents is in accordance with adopted regulations. Specifically, the facility does not provide orally and in writing, information for family and other visitors on safe food handling practices or safe reheating of food that is brought to residents. This is evidenced is as follows: The document titled Food Brought By Family/Visitors - SNF and dated 08/2019 documents that safe food handling practices will be explained to family/visitors in a language and format they understand. The facility policy for foods brought in by visitors was reviewed on 12/04/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. During an interview on 10/13/22 9:52 AM, Diet Technician #1 stated that families and visitors are not encouraged to bring food to residents; when families and visitors do bring food, it is requested that the food be only for the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to UNIVERSITY OF VERMONT HEALTH NETWORK — 3 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.3+0.7 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 1 of 53.0-2.0 vs chain
Quality measures 2 of 53.0-1.0 vs chain
The other 2 homes this chain runs (chain average 2.3★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
THE UNIVERSITY OF VERMONT HEALTH NETWORK INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2016
BOURGEOIS, LINDAIndividualCORPORATE DIRECTORsince 01/01/2019
DONOGHUE, KELLYIndividualCORPORATE DIRECTORsince 01/01/2022
GOERLITZ-CORYER, ELIZABETHIndividualCORPORATE DIRECTORsince 01/01/2022
GREGORY, RICHELLEIndividualCORPORATE DIRECTORsince 01/01/2022
MCAULIFFE, JOHNIndividualCORPORATE DIRECTORsince 01/01/2019
MCCULLUM, KEVINIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/29/2024
NILES, GRAHAMIndividualCORPORATE DIRECTORsince 01/01/2024
PRATHER, MONTICIAIndividualCORPORATE DIRECTORsince 01/01/2022
RECNY, THOMASIndividualCORPORATE DIRECTORsince 01/01/2016
RYAN, MOLLYIndividualCORPORATE DIRECTORsince 01/01/2024
VICENCIO, ELIZABETHIndividualCORPORATE DIRECTORsince 01/01/2012
WEBBER, RICHARDIndividualCORPORATE DIRECTORsince 01/01/2022
FESETTE, NEILIndividualCORPORATE OFFICERsince 01/01/2017
KOLLAR, MATEJIndividualCORPORATE OFFICERsince 04/01/2023
LEBEAU, MICHELLEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/29/2025

CMS files one row per role, so the 20 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in NY

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.

Typical monthly cost in New York
$15,528/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$7,110/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335442. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next